Author Question: When planning care for the immobile client, the nurse includes which of the following? 1. Assess ... (Read 17 times)

xroflmao · **on:** Jul 22, 2018

When planning care for the immobile client, the nurse includes which of the following?

1. Assess for complications resulting from immobility.
2. Plan for the client to obtain eight hours of uninterrupted sleep without repositioning.
3. Implement repositioning every hour.
4. Evaluate the client's ability to perform passive ROM.

Question 2

When assessing respirations in areas of higher elevation, the nurse anticipates which of the following?

1. Normal respirations for the age of the client
2. Increased respirations for the age of the client
3. See-saw respirations
4. Diminished breath sounds

smrtceo · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1
Rationale: The nurse uses the nursing process to care for the immobile client and assesses for complications resulting from lack of mobility. While sleep is important, the client who is unable to reposition themselves must be repositioned every two hours, not hourly. The client performs active, not passive, ROM.

Answer to Question 2

2
Rationale: At a higher altitude, there is less oxygen in the atmosphere, requiring faster respirations to obtain the same oxygen acquired at lower elevations. The respirations would increase to try to obtain more oxygen. See-saw respirations are uneven breathing, and diminished breath sounds are not a part of counting respirations.